Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Wednesday, July 11, 2007

If one is comfortable with their therapist and feels the therapist seems to know what they are doing, how much lack of improvement should one tolerate before deciding it's time for a change? I know it's impossible to talk about an exact time frame given different diagnoses and personalities and treatment progress, etc etc, but is there any indication?And if so, what should one do? Bring it up with one's therapist and see what happens, switch therapists, get a second opinion? ...I was in a situation where I made no progress after 40 sessions and 3 drugs, had no experience with other therapists, and didn't think the therapy was going anywhere, but my therapist seemed competent.

Wow, where do I begin? Our questioner uses the term "therapist", and I'm going to substitute "psychiatrist" while I think about this because I'm simply not qualified to answer this from the point of view of another mental health professional. For the sake of this particular question, the fact that I prescribe medications makes, I believe, a huge difference in both who seeks my services and how I view outcome. Oh, and if no one minds, I want to talk about this in a vacuum, free from the discussion of insurance, reimbursement, "medical necessity", and who deserves care.

People come to psychiatric treatment for a variety of reasons, but most commonly because they are having a constellation of symptoms which someone (the patient, a family member, their primary care physician) has identified as being indicative of a mental illness. In plain English: people come to see me because they're feeling badly or acting weirdly. The patient comes with, for example, a complaint of sadness, changes in sleep and/or appetite, hopelessness, decreased energy, thoughts of death or suicide, decreased interest and activity.

A second reason people seek treatment is because they have experienced an overwhelming stress and they feel they are not coping with it well: the stress has resulted in either subjective distress, an inability to function normally, or the stress has precipitated a full-blown psychiatric disorder (back to where we started). For the sake of discussion, we can lump these first two groups of people together as patients with specific symptoms they want resolved.

A third common reason for seeking psychiatric treatment is that the patient is unhappy with the course his life has taken and feels he has maladaptive patterns of behaving and/or interacting which interfere with his ability to love or to work to his full potential. Sometimes people in this situation have personality disorders. Generally, people do not seek psychiatric treatment if they are having normal reactions to bad events or if they have no symptoms and believe they didn't get their last promotion because of bad luck or something completely external to them.

Okay, so Patient Number One, with an acute onset of psychiatric disorder, wants his symptoms relieved. Often, medications are prescribed. Psychotherapy focuses on education about illness and support. People in a state of distress often feel an intense and powerful need to understand Why this has happened and want to talk about the precipitants of the episode, or if there are none obvious, their theories as to what may have gone wrong.

There is often a huge sense of relief simply in the telling of the story and the hopefulness of finding help. If the medications work, the patient often wants to end therapy or to come less often. People who are by nature a bit anxious often feel that regular therapy sessions keep them grounded and prevents recurrence. I don't know that they're right ( studies on Maintenance Psychotherapy, anyone?), however in those with repeated episodes of illness, if they are seen frequently it is easier to catch an episode and intervene early, and the patients who want to continue coming between episodes feel greatly comforted by psychotherapy for reasons that are sometimes difficult to articulate. One patient described therapy as a "safety net", and that's about as good as I've been able to get.

Let's move on to Patient Number Two: the person who is stuck in a bad place and thinks they should be getting more out of life. Sometimes people come to see me with a very specific concern: "I want to work on X" -- oh gosh, maybe feelings about a bad childhood, distress about a romantic relationship gone or going bad. These patients often talk for a few sessions, feel helped, and finish therapy quickly.

What about the patient with a personality disorder who repeatedly foils themselves or views life in a self-defeating way? These patients typically find me because they have a co-existing Axis I disorder -- meaning depression or anxiety or bipolar disorder, as in the last paragraph. But when their symptoms resolve with medications, their problems don't. These patients often continue with psychotherapy for a long time, and the therapy itself (and the therapist!) grow to have meaning above and beyond the issue of Fix the Problem, Doc. The end point becomes foggier, the treatment is more of a process, the goals may be clearly defined, but perhaps unattainable. And the treatment may start with the idea that progress will be slow and even painful. The relationship with the therapist may itself become a focus of attention, and this all gets muddled with what is going on with the illness and the meds and things are often just not so clear. Sometimes, it's not all that obvious exactly what is being worked on in psychotherapy and then, for lack of something that better describes what we do, therapy is deemed a "holding environment." I hate that term, and I like to know we're moving towards something, but that's just not always the case.

So How Long?

For someone seeing a psychiatrist with a psychiatric disorder, medications often provide relief. Medications take different amounts of time, not only to work, but to even tell if they are working. Typically, we say that antidepressants (just to use an example) take 3 to 6 weeks to work and they have to be given at high enough doses. If there is no improvement at all in a month, most psychiatrists will raise the dose or switch the medication. If there is partial response (some of the symptoms either resolved or lessened) then another medication -- an augmenting agent -- may be added. Sometimes it takes trying a bunch of medicines in a bunch of combinations, before results are seen, and this can take a while. If I start talking about antimanic agents and antipsychotics, we'll all be here for a while. As long as the patient is symptomatic and suffering, I believe this should be an active and aggressive process. Sometimes nothing works and all that's to be had for all the efforts are a lot of side effects.

For someone seeing a psychiatrist for an issue of dissatisfaction with their life, then it makes sense to stop and evaluate every few months. Are things getting better? Is there another way to go at the problem or something more or different that can be done? If the answer is repeatedly No Change at All, then it's reasonable to get another opinion or try something completely different.

Sometimes it's all very hard to quantify: even patients who don't get better, who continue to suffer or feel stuck, will identify therapy and the therapist as being helpful. Maybe they should get a second opinion, and often they don't want to.

I talk a lot. Please don't count my words. And don't forget to tell us who you are on our sidebar.

32
comments:

Interesting discussion and I come at it from a different viewpoint, not being a psychiatrist. In therapy, sometimes the process can get "stuck" so to speak, sometimes that's just a natural part of the process. When that happens, it can be useful to stop and review what is/isn't going on..maybe another approach is needed, maybe, as you suggest, another opinion should be sought, maybe (in my world) medication may be needed and the sensible thing is to refer on to a psychiatrist, if the patient doesn't have one already. Sometimes just discussing the 'block' is all that's necessary...but when it isn't, I think the mental health professional should be open to trying something new...whatever form that takes.HP

Well, this is a little sideways of the topic, but I can tell you that my mouth-watering major university medical school health insurance does not pay for psychotherapy with a psychiatrist. Medication assessment and management, but not psychotherapy. Secondly, I personally felt like Salvador Minuchin, a veritable master of insight, compared to my resident colleagues, I believe, because I had a graduate degree in psychology. Pretty much any time a "doctor" spoke about anything but meds, the nurses, social workers, and psychologists rolled their eyes. I was learning so little and receiving such inadequate supervision (except for "disorder focused" medicine), that I finally demanded a new supervisor. My own boss lists on her CV that she practiced psychotherapy for 2 years "under the supervision" of a Marital & Family Therapist. I am NOT generalizing, but for my money - and I guess that means the co-payment - I'm going to a psychologist.

I see both a psychiatrist and a psychologist, both on an as-needed basis. If I had to choose, I would pick the psychiatrist. Easily. Without thinking. Even though I like my psychologist.

If a psychiatrist prescribes you a med and it isn't helping and it is making you worse, they try something else.

If a psychologist plays manipulative mind games with you and it isn't helping and it is making you worse, they say Good! Therapy is Supposed to Hurt! We're doing Such Good Work! And whatever soul-destroying techniques they've been using... they ramp up.

Psychiatrists seem more outcome-oriented. They just want your functioning to improve. Psychologists seem to think of psychotherapy as something good in itself independent of outcomes, so that either improved outcome or tears in therapy are signs that something good is happening.

As someone who has to live with myself, I'm very much in favour of good outcomes.

And as someone with scientific training, the theory that psychotherapy that leads to bad outcomes can still be good in itself is problematic to me on the grounds that there is no feedback loop to let anyone know when the approach is wrong. If an approach can never be shown to be wrong, the patient is helpess and the therapist cannot learn.

I must say that there are many months in a row where it seems like no progress is being made, but the patience of my psychologist is a HUGE factor in my continuing to trust him . . . . also, it turns out that there's alot going on subconsciously (who'da thunk? lol) and I'll find stuff I've learned in therapy, or through therapy, BE there for me when the shit hits the fan, so to speak, in life . . . or in seemingly small ways, but they eventually add up to SOMETHING, I'll find my inner therapist (I guess my view of what he might say to me when confronted w/something I'm having a hard time with, and I'm trying to figure out how to deal with it) saying things from therapy, reinforcing and building up any sense of confidence and efficacy I have (efficacy, that's a HUGE problem for me, my lack of a sense of it, I mean, er, my problems feeling efficacious, er, I can't explain what I mean at the mo).

Anyway . . . a huge part, a HUGE part of my HURT, my pain of who I am, is that no one has ever been patient with me, cared enough to pay attention for more than a fleeting moment, if that. I'm not worth more.

Within a few weeks of starting therapy, as I was struggling to express something, my psychologist hit it right on the head when he said, "You want to be heard."

I immediately dissolved into a sobbing mess of tears as I realized that that was what I had been struggling to put into words, that I couldn't figure out, because to have said it myself, would have been to face the fact that no one wanted to hear me, which I realized also as I was sobbing. He said it was one of my core issues, he thought.

Anyway, in his acceptance of me, I learn to accept myself more, I suppose, although that's hard to gauge or measure, and I can only really do that for a period of therapy months or more after that particular period of therapy . . . . .

It's hard to explain, but as you know and have conveyed, it is difficult to describe some of what therapy is, anyway.

I just saw my new iatrist for the second time, today. He was half an hour late getting to the office (I was first for the day). Good thing I was 20 minutes late myself or I would have been really pissed, lol.

I just seem to need . . . a tender touch, gentle . . . I need patience. There's a fragileness in some ways, to me, especially in the trust department . . . that someone will BE there 8 months down the line, still listening to me, and HEARING me, and helping me . . . the patience of the listener showing me that I am worth it, among other things.

Alison wrote "If a psychologist plays manipulative mind games with you and it isn't helping and it is making you worse, they say Good! Therapy is Supposed to Hurt! We're doing Such Good Work! And whatever soul-destroying techniques they've been using... they ramp up."

I'd call that a sweeping generalisation and maybe you have been particularly unlucky with your psychologists. After all, there's good and bad in any profession.

It's true that working through some issues can be painful...that's why they've become issues in the first place...but a good psychologist won't press on regardless without consideration to the impact on the patient. Sometimes all the CBT or whatever else therapies in the world aren't going to help..sometimes a patient will need medical management to get some symptoms under control up front...sometimes the best decision for the patient is to refer on to a psychiatrist.

I didn't read Dinah's post as a discussion of the benefits of psychiatrists versus psychologists..I read it as a discussion of how much progress should reasonably be expected and that's a valid question regardless of the mental practitioner involved.

Thanks Dinah. I've been letting this marinate a while. I should've said I am in this situation rather than I was in it.

The therapist is a psychologist, not a psychiatrist, but I still thought you might be able to give some valuable perspective. I guess what I've taken from this is that I need to be more aggressive with the antidepressants. I've just had my primary doc managing it but I don't see her often.

I think part of my problem though is that I just don't like to talk. Maybe I'm not cut out for therapy, CBT didn't work and we're going to try IPT but I don't really see how it will help, 'it's just talking'. I just don't feel affected by opening up, other than anxiety. Haven't been very successful at it either because of that. Can't blame my therapist for all that. Don't know if changing therapists would change anything, but doubt it would. Ha maybe pessimism is my problem, though that might be an effect not a cause. I dunno, I just don't have the energy to take the initiative and deal with it all.

Yes, it is a sweeping generalisation. Perhaps I've been particularly unlucky; perhaps it's me; but this has been my experience. I should have been more clear: I speak for myself and my experience. If someone else posts that they have worked with several therapists, all of whom have brought them understanding and helped them improve their lives, I wouldn't argue with them.

"It's true that working through some issues can be painful...that's why they've become issues in the first place...but a good psychologist won't press on regardless without consideration to the impact on the patient."

See, you're working from the assumption that mental health is about 'issues.' That if you discuss the 'issues' long enough, with enough hankies, and struggle with your therapist, you will be able to get a handle on your 'issues.' That's very much a psychotherapist point of view. It's one-sided.

My psychiatrist is happy for me if I see a therapist and it seems to help. If I see a therapist and I become suicidal and unable to work, my psychiatrist will present the hypothesis that perhaps that particular therapy isn't right for me right now. And that just maybe I should quit therapy and stop torturing myself.

Let's imagine you don't actually have 'issues.' Let's imagine instead that you are moody in a way that can plausibly be linked to a genetic tendency, and that this moodiness has made it difficult for you to follow through on plans - like a college education. Let's imagine that you are 33 years old with an income of CAD$300 per month and tolerating an abusive relationship for financial reasons. Of course you have 'issues,' as everyone does, but you feel as though you've worked them out (you have a friend who is a clinical psychologist, who knows you well, and who thinks you have worked them out). You do not see your 'issues' as being what is making life so difficult for you.

Now, let's imagine that you see a series of psychologists who are convinced that a frustrated 33 year old woman owes all her problems to her mother, and who do not want to hear about anything else. Who demand to know, "Who lied to you that you were stupid?" when in fact nobody has ever suggested that you were stupid. Who refuse to take "nobody" for an answer.

I actually wanted medical help for my 'moodiness' (and have it now, but nearly died trying to get it). Failing that, I wanted coaching and encouragement to help me manage my life in the present day. I was told I was not depressed, and that if I insisted I was depressed then I must be a manipulative borderline personality. (I know, you're thinking that if several professionals thought the same thing that maybe they are right; but if you are bipolar II with atypical depression - I have never asked my psychiatrist for a diagnosis, but the meds she prescribes me are consistent with something not unlike this - then you may be perky and engaged in the therapist's office and revert to your default of locking yourself in a dark room and trying to stop breathing once you get home. This would make it difficult for a therapist to see you as depressed, and easy for them to see you as someone trying to get attention by claiming - not very convincingly - to be depressed.)

Once I started seeing my psychiatrist - every couple of weeks for half an hour at first, twice a year for half an hour now - I pretty much gave up on therapy. When life gets too much for me to handle alone, I have a therapist I see who coaches and encourages me. I see her maybe five times a year. That's it. So you would think that if I had 'issues' that needed resolving that they would still be poisoning my life.

Actually, no. Within a year of starting medication, I went from CAD$300 a month to extraordinarily well paid, challenging full-time work. I have kept my job for almost ten years now. I asked my abusive partner to move out. I dated for a while and have been happily married for over four years. We have bought a small apartment building together. I have taken up running.

All this by myself, without therapy. Gosh. Whoda thunk it.

Certainly not my therapists. Because if I claimed I didn't have 'issues' I wanted to work on, I was in denial. If I claimed I was on good terms with my mother, I was in denial. (This was a fascinating theme actually, because therapists never tried to force me to talk about my father, with whom I have a more complicated relationship.) If I claimed I was depressed, I was attention-seeking. If I pointed out that if I was not offered any hope then the struggle to stay alive was going to become progressively more difficult, then I was definitely borderline and my only hope was more therapy, more hard work, more frustration and banging my head against a wall, more putting myself in a situation where my perception of my self, my present and my past would be challenged over and over again. (This is actually a CIA-approved torture technique, by the way.)

According to therapists, I was wrong about every single one of my concerns. If I tried to promote my point of view, I was resisting therapy. They knew better than me. So you would think that if I were so bad and therapy-resistant as to actually quit therapy, that I would be doomed.

And gosh, I'm doing better than ever. How could that be?

Sure, I still harbour resentment against a mental health system that can work against people who are seeking help precisely because they do not trust their own judgement.

But I hang out on this site in the hopes of gaining some insight into how help-seekers are supposed to protect themselves in these situations, because I cling to the belief that they can, that if I just could find the key I could trust the system again... my psychiatrist will be retiring in the foreseeable future and I'm very afraid of what I will have to go through to find someone else I can work with.

Realistically, I know that next time, I can go with credentials. "Dr X says meds help, so it must be true." Next time, I won't have to try to be taken seriously, because Dr X will (I hope) be taken seriously.

Of course, this pisses me off no end: why will you believe Dr X and not me?

Anyway. My point was that psychiatrists (like Dinah) tend to have a fairly straightforward point of view: "You're supposed to get better." An easily identified endpoint and a clear feedback loop.

Psychotherapists do not always have the same clear focus. It often seems to be more like the following: "You're supposed to develop insight, then get better."

If you aren't getting better, then we're still fine as long as you're developing insight. Getting worse: that too could be part of the process of developing insight. This lack of a clear feedback loop can place the patient in danger particularly when working with a less-experienced, more-dogmatic, less-trained or simply less-bright therapist.

The therapist and the patient may have an honest disagreement as to whether insight is being developed and the benefits of the insight. The point of danger here is that the patient in this case must always defer to the therapist as to whether the patient's insight is accurate. This undermines the patient's ability to self-advocate.

hp, as you say perhaps a good psychotherapist will pull back if a patient is actually getting worse. But because the purpose of psychotherapy is often not so clear, then its effectiveness is also not so clear and this leaves room for less-competent psychotherapists to make (potentially serious) errors in judgement.

This is why I have in the past specifically sought CBT and become so frustrated when I meet a therapist who says, 'no, you don't really want CBT, you really want to talk about your mother.' (Which I have actually had a therapist say to me. Tears welled up, but I couldn't think of any words to use to help myself.) CBT has a clear endpoint - getting better in a defined way - and the development of insight is secondary.

I don't try to get CBT any more; I asked around and a friend told me about a therapist who 'was nice to me.' So in my first interview with her I told her that I wanted to hire her to be nice to me. She was a little puzzled, but does a good job of it. It seems to help. I might even develop some insight, but that's secondary to the coaching and encouragement and being nice, which is the predefined purpose of the therapy.

Back to the original post, going back to the therapist to clarify the goals of therapy and the means that this particular therapy is supposed to be using to achieve these goals can help determine whether to continue therapy. Sometimes it doesn't help and it's not the fault of the patient. Sometimes the patient and the therapist are not a match. Sometimes the patient has 'issues' that are more amenable to medical therapy than talk therapy.

The possibility that continuing therapy is inappropriate must be seriously entertained by both patient and therapist. If this idea is seriously examined and agreed to be false, then therapy should probably continue.

If you cannot entertain the possibility that therapy is being ineffective or even damaging in a particular case, then you do not have a way of evaluating the benefits of therapy. Ultimately this could mean that you are a potential danger to your patients.

Alison - my experiences of therapy have been different from yours. Over the years, I have had a variety of different kinds of talking therapies with a variety of therapists - including a psychiatrist, a GP, psychiatric nurses, and a counsellor. I know many people who have had a variety of therapies.

My view is that it's horses for courses: what works for one person may not work for another. Also, different therapists from the same profession may use different schools of therapy. Just because someone is a doctor doesn't mean they will use the same school of therapy as all doctors; ditto psychologists, nurses, counsellors etc.

Personally, my best experience has been with a student Rogerian counsellor, and my worst experience has been with a consultant psychiatrist in psychotherapy. (I'm not sure if you call them consultants in America, but they're the highest level of fully qualified doctors.) But I wouldn't infer from that that Rogerian counsellors are always better than psychiatrists in psychotherapy.

Have you ever disagreed with a psychiatrist or a talk therapist about whether therapy is helping or not?

How do you handle the discussion?

Because my experience is of utter disempowerment when I feel that therapy isn't helping, as I don't have any standards to use. (I feel less disempowered relative to meds than talk, though. Meds are easy: I can just not take them.) That's why I get so riled up about talk therapy, and why I'm still looking for answers.

It's always a question of odds, of course. I had a horrible experience with a psychiatrist at a hospital. I only ever saw him once, but because of that one interaction I do not dare attempt to access hospital-based mental health services in this province ever again. I had another horrible experience with a psychiatrist and a psychologist who were friends.

The person who ultimately intervened to save my life was a psychologist.

So yes, I am quite aware that it's about the odds.

I still stubbornly stick to my thesis that the theory that therapy can be a good thing in itself even if it does not appear to be leading to a good outcome leaves the holder of this theory more vulnerable to mistakes in judgement.

That doesn't mean that all holders of the theory make mistakes, nor that only holders of the theory do. But I think it affects perspective in a risky way, and I think that both patient and therapist need to be aware of the risk.

(I take lots of risks in life. Risk isn't necessarily bad. But I like to be able to make an informed decision.)

It's easy to forget that no treatment--medical or psychological--is 100% effective, 100% of the time, for 100% of individuals. There are psychotherapies which have been shown to be harmful more often than helpful (rebirthing and "reparative" therapy, to name but 2) and then there are some which are helpful to some people and not to others.

For example, CBT has historically been phenomenally ineffective for me because I already think too much--and can counter-argue just about anything. I have no doubt that the CBT folks I met were fantastic therapists; it's just that the approach was wrong. Humanistic/existential therapy, on the other hand, was hugely effective for me.

An analogy: When I was about 3, I got an infection of some sort, for which my pediatrician decided to try a sulfa drug. I developed a fever. He figured that the fever was from the infection, so he upped the dose of the antibiotic--whereupon I became extremely ill. The proverbial light bulb came on--perhaps I was allergic to sulfa drugs!--and once he switched the treatment to amoxycillin, my fever disappeared and the infection began to clear up. Had he not been willing to re-evaluate his approach, I might have died, or at the very least cooked my little toddler brains.

There is a place for feedback in all kinds of treatment. But the feedback process breaks down if (1) the provider is not willing to listen to the patient; or (2) the patient does not provide the feedback in the first place.

I think I was particularly clumsy in choosing the word 'issues'...I certainly don't believe everything must relate to things that people have experienced or had done to them..I share your view that some people just "are"...

You wrote "If you cannot entertain the possibility that therapy is being ineffective or even damaging in a particular case, then you do not have a way of evaluating the benefits of therapy. Ultimately this could mean that you are a potential danger to your patients.."

I certainly can entertain the possibility that therapy is ineffective or damaging for some..no therapy or medical treament is 100% effective...I have referred several patients on to the sole care of a psychiatrist who I feel would be better positioned to help...What's important at the end of the day is helping the patient to get better..it's not about me and a concern about not being able to 'fix' someone...it's simply about doing whatever is best for my patient and being open to the fact that what I do may not be the best fit.

Ah and ps...I'm a CBT practitioner mainly..although I do use other therapeutic practices where relevant....so there are specific goals agreed with the patient upfront...one of which is to 'get better within a specified timeframe' whatever specific form that takes for the patient..and sometimes that will change as therapy progresses.

I'm really sorry you've had such bad experiences. It's excellent though that you finally found someone who is a good fit for you.

Yes, that's exactly the point I've been ranting/rambling on and on trying to make, only much more succinct!

It's not about the particular approach, it's about having (and using) the tools to evaluate its effectiveness. If you don't have the tools to evaluate the effectiveness of what you are doing, you can hurt someone. Even yourself.

That's precisely my point.

"Psychiatrists seem more outcome-oriented. They just want your functioning to improve. Psychologists seem to think of psychotherapy as something good in itself independent of outcomes... ."

(Emphasis added.)

My hobby horse today is not that a particular approach is better than another - psychiatrists and psychologists both come in many flavours - but that I have never been told by a therapist that she isn't helping and that she'll refer me to someone else. Never.

Whereas I have been referred by doctors, and I have had doctors try different things when the first things didn't work.

"the feedback process breaks down if (1) the provider is not willing to listen to the patient; or (2) the patient does not provide the feedback in the first place."

Or... (3) the provider listens just fine but applies an interpretation that invalidates the patient's statement.

I speak up. Sometimes I'm listened to, sometimes I'm not. Right now I have enough experience behind me - and enough other resources in place - that I would be willing to fire a therapist just because I felt like it. But back then when I was sicker and more vulnerable, I was not. And in the future, if I really needed a therapist - say I became so depressed that I lost my job and my insurance and my beloved and went begging for scraps of short-term therapy dispensed by nurses at public clinics - I would take what I could get and if I didn't benefit I would feel as if it were my fault. That's why I feel so strongly that it can't be solely the responsibility of the patient to evaluate the effectiveness of therapy. Patients may not be in a position to do so.

If I had so much confidence in my judgement and my ability to advocate effectively for myself that I could direct my therapy, I would not need therapy. (I have that confidence now, and I'm pretty directive with my current therapist, but I'm not really sick either. Just not coping as well as I want. I can get pretty upset with people who suggest that it's my fault for not being more directive in therapy when I am really sick. There's a reason that very phisically sick people are usually accompanied by a friend or family member for a medical appointment. I really resent the suggestion that a mentally ill person should be able to advocate more effectively for herself than a physically ill person can. Yes, I know that we all have to take responsibility for ourselves. I do take responsibility for myself. But if I'm so sick I need help to stay alive, don't tell me it's my fault if someone whose job is to know better is f***ing with my head.

I'm only up to hp's response to Alison, right after my first comment (hi hp, hi Alison!).

I must say that my psychologist said, early on, that we could back off, if anything got too bad, too intense, too . . . something. I can't remember how he put it. Anyway, a few months later, we were talking about something difficult, and I started having a squeezing 'round my chest. It turned into an iron band that squoze (squeezed?) tighter and tighter, around my lungs and heart and chest and sides and stuff. It hurt like hell, and I couldn't breathe; my breathing was shallower and harder to get, harder to get air, because I physically couldn't breathe much because of this giant fist of iron squeezing me to death.

Anyway, before it got to where I couldn't speak, I got across that I was having a squeezing, that I couldn't breathe (although he could probably tell, as there were audible efforts by me to try to get more breath, and I slid and slumped down in the couch, flattening out in a reflexive effort to give my lungs more room or something; I was desperate.

He immediately started speaking in the most comforting, most soothing, most protective voice that I was safe, and he said other stuff, to help me back off from this whatever it was. Also, I was fighting mightily inside, as I was NOT going to let this win.

Anyway . . . . I don't mention this as an ologist vs. iatrist (psych) thing, just as an example that I think good professions in mental health, will recognize that there is a pushing too far, or that there are times when you need to reassure the patient of their safety and help them by backing off, not by making them miserable or playing mind games.

There are bad ones out there though, in all fields. It really sucks that bad ones in mental health fields are in a position to harm people in ways Alison mentions. That's sad.

Just wanted to illustrate what hp was saying.

I'll read the rest of the comments tomorrow, I've not gone to bed ye tand it is almost 5 am my time.

What is it about this new medication that makes me all existentialist (non sequitur to the discussion at hand, tho). I wish I could just quit THINKING about everything, hang it all (the worries, etc.) and just LIVE.

I see both - t-doc normally twice a week at the moment, and p-doc once a week.

Started seeing t-doc when I was still with previous p-doc, because I felt that we'd been together so long that he knew everything about me and that a different approach might help.

Before that though, I used to see him even when things were going well. I'd stretch appts to every 3 or 4 months, andd we'd basically just have coffee and chat. It was important to me that when the wheels came off the next time, he'd at least have some idea of what had been happening in between.

Not going to be able to do that with current p-doc. If it ever actually gets good ever again. He's just too busy. It's important to him though that I see t-doc, so that she can do the hand-holding. So yeah, 'maintenance therapy' to me is a good idea.

I am a psychiatrist and a psychotherapist: they sometimes roll us into one blob. I believe it works best that way.

Alison wrote: "Within a year of starting medication, I went from CAD$300 a month to extraordinarily well paid, challenging full-time work. I have kept my job for almost ten years now. I asked my abusive partner to move out. I dated for a while and have been happily married for over four years. We have bought a small apartment building together. I have taken up running. All this by myself, without therapy. Gosh. Whoda thunk it."

Sounds like you've made huge progress.

Therapy helps some people some of the time. Medicines help some people some of the time. Both can be hugely helpful and very powerful, but people heal and progress for an assortment of reasons, sometimes for internal reasons, sometimes for external reasons, and some of them totally unrelated to psychiatric interventions.

Alison's remark, "If a psychologist plays manipulative mind games with you and it isn't helping and it is making you worse, they say Good! Therapy is Supposed to Hurt! We're doing Such Good Work! And whatever soul-destroying techniques they've been using... they ramp up." is what made me have to comment!

First, as someone who's had bad therapists, I can see where you're coming from. Second, as a psychologist, I'm in agony.

My very first thought was, If that's how you feel about your therapist after multiple sessions, it's not working. Period. You need to run for your life and find a new therapist.

Forget "competent." I genuinely believe you should adore your therapist, and that you should feel s/he respects you in return.

Yes, there are rotten therapists, but if you feel you're being manipulated, that your therapist is a sadist, or that s/he's playing mind games...s/he's not the therapist for you. (But somebody probably likes them -- look at Dr. Phil. Don't get me started on Dr. Phil. That ain't therapy, folks.)

As HP said, goals are important. CBT practitioners are often more explicit about setting them, but you have the right to know the plan (and understand it) regardless.

Now, I was trained in the last 10 years, and my completely unscientific (and even more biased!) observation is that younger therapists can sometimes be a little more flexible. Blame that on not being set in their ways, blame that on an eagerness to find something that works and not "fail," blame it on being trained in a more integrative fashion, or blame it on the fact that a lot fewer people come out of grad school purists. (I think all of us were integrative/biopsychosocial to some some extent. HP sounds like s/he is the same way.)

Particularly in a world where insurance can be stingy, you deserve results. And oh yeah, you're there because you want to feel better...NOW.

I'm a big advocate of teaching clients the techniques so they can use them on themselves and not have to see me indefinitely.

I'm also a big advocate of meds when they're necessary, but I believe (and remember, I'm biased) that meds can only help so much if you're not dealing with whatever's causing the problem.

Biochemical problems are biochemical problems, but they usually have to be triggered by the environment (we call that diathesis stress theory), and they're often exacerbated by the environment.

And even if you have a problem like bipolar disorder or schizophrenia or OCD, things that are very biochemical in nature, learning to cope better with them is always a boon. They can help you take fewer medications and deal with how badly your remaining symptoms affect your day-to-day life. And for all the wonders of meds, they all have side effects, some of them less pleasant than others.

I say all of this with the caveat that I've almost always been fortunate to work closely with the psychiatrist who's seeing my client, and trust and communication between your psychologist/counselor/social worker/etc. and psychiatrist can be almost as important as your trust in each of them.

For anonymous...research shows (and personal experience says) that the approach isn't most important, it's the relationship with the therapist that helps most. (That may not be the case with a psychiatrist, since it's a different kind of relationship, though it certainly helps to like your psychiatrist!) You actually can't be "not cut out for therapy" unless you don't want to be there. (Truly. Promise. Therapy is about being a human being, not about whether you can play the game right.)

Alison also said, "If I had so much confidence in my judgement and my ability to advocate effectively for myself that I could direct my therapy, I would not need therapy."

That's a good point. I'd argue, though, that if people were better educated about what to expect and how to ask questions, it would be easier. I don't care for the pure "consumer" approach to therapy, because it feels (to me) like it assumes the client should get whatever s/he wants, and sometimes s/he needs to hear some things s/he doesn't want to to get where s/he wants. I mean, you might not want surgery to remove a tumor, but you get it because it can save your life.

People often feel that their therapist is "all right" or "competent." That's not good enough, because the relationship is what's healing. Albert Ellis' assertions that his clients could hate him because REBT (a form of CBT) works, research doesn't agree.

When you end up with someone who's a good match for you, you'll start to see results. If you've done 10 sessions and seen NO results (and what sarebear is talking about counts, obviously), your therapist either better have some thoughts for you or you need to move on.

If you hired a car mechanic who never fixed anything on your car, you'd hire someone new. If you hired someone to remodel your house who just stood in the front hall and said you're rushing them, you'd hire someone new.

You go to therapy because you need change. If you're genuinely willing to work to see that change and you don't feel your therapist is able to help with that, move on.

Alison, woops, I wouldn't have gone into my example if I'd read further.

But then later, I meantion how I DO think bad mental health professionals are in a sadly powerful position when it comes to how much and the kind of harm they can do people.

What follows are my thoughts and feelings on some stuff the post and comments have brought up in me, but they aren't directed towards anyone in particular, nor intended as a lecture or anything. The therapeutic relationship, the working on it/at it/addressing things/feelings/perceptions that come up involving it/& the therapist, is something that I feel is very important, and a subject that I'm passionate about, at least to a degree; I feel it can be empowering to address stuff like that, to know and feel and do and interact in a way that is more . . . interactive, more . . . two-sided . . . than the interaction between therapist and patient can feel like at times (sometimes it can feel very one-sided, like the therapist is very powerful, etc.); "Hey, I can disagree with him; we can have a discussion about that, explore that, and if I still disagree after that, IT'S OKAY, the world will not fall apart, and HE'S OKAY with my having a different opinion, etc., too!";

When a "professional" (I use the term loosely, as it regards bad practitioners lol) invalidates the things you say and stuff, that you try to bring up about therapy and other stuff, there's a term called gas-lighting (I think) or something like that.

There's a section in the book, "In Session" that talks about, in part of, about that, and how stuff like that can happen, and what the patient can do (I agree strongly, though, that the mentally ill are often not "up" to advocating for themselves, at least not fully, or as assertively as would befit them. Myself being one of these.)

I actually felt kind of lost and like I didn't know the "rules" of therapy, well, not really rules, but had no "script" as the term is sometimes, I had no framework or anything to "fit" my new venture into therapy, into. Probably good that I didn't have a bunch of stereotypes, but some explanatory information about the process and what might be expected, or about the therapeutic process, would have been great; I felt like I was in the wilderness w/out a compass.

When I read the book In Session, though, I felt more empowered to be more . . . . assertive/active/aggressive/less passive in therapy (none of those words are what I'm looking for, but aspects of them are). I felt like I wasn't in an unknown quicksand (fear of the unknown is a biggie for me), ie, I had more of a sense of mastery about understanding what therapy could be for me, about understanding my role in therapy (I had ALWAYS, though, come to therapy with a deep desire to work, change, etc., as well as between appt.s, although I've discovered sometimes change only comes as fast or slow as it comes, sometimes) . . . I had and have a sense of empowerment; I can disagree with my psychologist, and, in fact, there is something that has tendrils attached to issues of mine, that we DO disagree on. The thing is, he respects me and my right to hold my own point of view, which, when mental health professionals don't, can be a big problem. As you say. This problem crops up from time to time, but I bring forward any issues I have with HIM, in therapy.

There's been some talk sometimes on this blog that therapy can sometimes become too much about the relationship between the patient and therapist; that's so, but my psychologist has told me that the biggest indicator of how effective/successful therapy will/can/could be is the quality of the therapeutic relationship between therapist and patient/client. With this in mind, we sometimes discuss issues regarding the & our therapeutic relationship, as it benefits ME greatly to clear things up, work through these things, for several reasons: A), because keeping the therapeutic relationship clear, trustworthy, healthy, etc. means that I'll be having a good quality of therapeutic relationship, and thus, increase the effectiveness and success of therapy, thus, improving my health; B)because bringing up uncomfortable interpersonal issues (as relates to me interacting with him, I'm not talking about out of boundaries stuff like asking him about his social life or asking him to change his hair color cause I don't like it (that's not an issue, just something plucked out of thin air)) is good for me, as well as teaches me/is a good model for teaching me about bringing up interpersonal issues with others (obviously, with him is safer, but it's still a good learning opportunity); C)in order to be able to be completely up front about uncomfortable things, if I DON'T clear the air periodically about issues, feelings, what-have-you, that may have arisen over time inside me regarding him, therapy, his office, my perceptions of him, anything like that, then it becomes more difficult and uncomfortable to bring up my deep, embarrassing things or whatnot; this stuff is HARD ENOUGH that I want to make sure to make it as "easy" as possible, I owe that to myself (at least, to the person I once thought I was, the person I hope I can be, maybe the person I maybe, maybe, perhaps, could be buried deep down in there somewhere) . . . . D)every time I do "work" the therapeutic relationship with him, work on it with him, together, I learn that alot of my fears, angers, that sort of thing that were starting to crop up between us (from my side of things) were, in CBT terms, "mind reading", "overgeneralization", "magnification", etc., et. al. This, again, is a positive learning experience and is a positive reinforcement, and is positively delightful, and delightfully surprising to learn that his opinions of me weren't judgmental like I was starting to fear before I cleared the air again, or whatever I was thinking/feeling/worrying/agitated about. E)I touched on this in a different way/from a different angle above, but another point is that since working on the quality of the therapeutic relationship, is directly related to how effective/succesful therapy will be for me, is directly related to improving myself, it is a new (for me), powerful, self-care strategy to do so; it is taking care of MYSELF, by taking care to maintain the healthiness of the therapeutic relationship, of checking inside myself to see if any resentments or desires to hide anything or whatnot have cropped up, and then, though this is difficult, facing myself, those issues, and him, in bringing them up in therapy. I am SO SO happy that I got a psychologist who is willing and ready to work together with me on this; not all therapists are comfortable enough with themselves to do so, not all therapists are . . . . well-versed enough in how important that is? Or some can't accept the questioning of the therapist's technique or other stuff that can happen in this, hey, let's talk about the therapeutic relationship/process, process . . . some can't look past their own pride/ego etc., to do that with the patient, for the patient's benefit. F) Doing this is also valuable, because therapists are human; they inevitably make mistakes, as all people do; if I have addressed awkward things/feelings/issues about him or us (us as in, our working relationship/partnership) before (some of it REALLY embarrasing, at times, that one would generally be mortified to bring up with another person!) . . . then it makes it "easier" (not that it's easy by any means, but "easier") to address these things with him. G)Working the therapeutic relationship, as we call it, is also beneficial in that it increases my sense of efficacy, it increases my sense of knowing a bit more about trusting my instincts or feelings, and when and what types of things maybe are questionable &/or possible distortions . . . it teaches me to listen to myself, my thoughts and feelings, to what's important to me, that my thoughts, feelings, instincts DO matter . . . that I AM a full person (well, I don't FEEL like one, but hopefully I'll get to that point), a full participant in a two-way interchange, communication, relationship (obviously, the therapeutic relationship is different than any other; it's not like he's sharing his troubles etc. with ME, but still, he's sharing his expertise, knowledge, skill, experience, personality (to some degree, his personality affects our interaction, although I know therapists are trained to screen out stuff from inside themselves, to some degree or another, and some are more successful than others, to varying degrees) . . . he's INTERACTING with me, there's a give and take, a back and forth. DOING all this teaches me that it's POSSIBLE for me to BE, to be IN the moment, to exist as part of a team (different kinds of teams, obviously my marriage is a MUCH different kind of team than my working partnership/therapy with my psychologist), to be EFFECTIVE in an interpersonal situation/interaction .. . . . to be ME in that, and that's OKAY (maybe! well, I hope to get to feel that someday, and maybe could even aspire to feeling like, even, that that's GOOD . . . one can hope, faintly, at the mo.) . . . .

Anyway. Obviously I have a lot to say about the therapeutic relationship, lol. This could be a whole post or three of its own.

I know I've got some posts about it in my archives on my blog; this comment I've just done, has laid out and articulated some things/thoughts/feelings that I haven't laid out before, so I'm glad about that, too . . . .

Sorry to go on so long, but I think it was a VERY good thing.

For Alison, again; are there any organizations where you are, like NAMI or DBA? They sometimes have advocates that can help you. Help empower you, and stuff. Also, going to a support group could help; I only went twice, as I don't have a way to get there, but it was EXTREMELY beneficial; one brief example -

One lady, whom I seemed to identify with alot, related that her therapist said she'd have her suicidal ideation for her whole life. I thought, "That's a load of crap; you are basically telling her that there's no hope at stopping those thoughts, that there's no poing to working on it, that there's no poing even, to fighting them is implied, even, in his telling her that".

I can't say anyone else should fight stuff that seems hopeless, but I've been fighting stuff for decades that still knocks me down repeatedly. I eventually get back up and keep swinging, though. If that therapist had told me that, I'd have fired him (don't know if I'da known I had enough power, emotionally and intellectually, in the therapeutic relationship, before I read that book, to do so, but at least i know it now) on the spot.

As John Locke (and, once, Ben Linus, and Jack) on Lost says, "DON'T TELL ME what I CAN'T DO!"

Going to group helps give perspective, helps see others' situations, has others see yours and offer advice, etc., acts as a springboard, as a check even on hey, is this guy just messing with me, or what?

Please, I want to be clear: it's not that I favour medication over psychotherapy, though that is what worked for me. I do have a therapist I like who I see when I need to.

What I am saying is: *if* a therapist thinks that therapy *can* be good in and of itself even if the patient is not improving or is deteriorating, *then* that therapist's ability to decide that therapy is not helping (or is actully being harmful) is compromised.

This is important, because sometimes therapy doesn't help. A therapist should be able to accept this idea and permit (or encourage!) a patient to move on. The way hp does, for instance.

I do not see the same conflict for doctors offering medical treatment because I have never heard of a doctor who thinks that taking pills can be a good thing in itself even if they aren't helping and are making you sicker. That makes it easier for them to make decisions about whether to continue a particular medical treatment or not.

Yes, medication worked for me. Yes, I am resentful that people who offer only psychotherapy told me it wouldn't, that I needed to work on my issues instead. That in one case they actively interfered with me accessing medical treatment. But that doesn't mean that I think medication is appropriate for everyone or that psychotherapy is always ineffective. (If I thought that psychotherapy was always ineffective, I wouldn't be seeing a psychotherapist.)

I repeat: the concern I have is that talk therapists seem to have a harder time deciding when to terminate or refer than psychiatrists do. My thesis is that this is because a talk therapist is burdened with a more complex agenda and therefore a more complex decision-making process.

Clearly some therapists handle this extra burden easily, without conflict, but equally clearly - some don't.

At the risk of beating a dead horse... DBT has a nice philosophy about "failures" in treatment.

It is not the client who fails the therapy; it is the therapy that fails the patient.

Carolyn, I completely agree with pretty much your entire comment (yeah, psychologists trained in the past 10 years!!) especially the part about helping clients grow to the point where they don't need you anymore. Or, as another therapist I know puts it, "My role in this relationship is to render myself obsolete."

And Alison--your point about termination is well-taken... and, I think, applies even when the treatment is med management only. Even after all the meds are tapered off and withdrawn, one still has to figure out when to stop doing periodic check-in visits!

I get that, Alison; I just chose to comment about aspects that were near and dear to me, lol!

I would bet that more often than one might want to think about, that for some therapists it depends on how thriving or not their practice is, and if it's not, that probably also affects their ability to properly decide proper termination.

Oh, Sarebear, I wasn't responding to your thread - you have such a lovely string of comments about long-term therapy. I didn't mean to ignore you, but your thread really stands on its own and deserves its own responses.

"Biochemical problems are biochemical problems, but they usually have to be triggered by the environment (we call that diathesis stress theory), and they're often exacerbated by the environment."

Absolutely. But depression can be triggered by smaller and smaller events over time - that's the "kindling" theory. Eventually the environment can become pretty much irrelevant as a trigger - such minor things can trigger a depressive response that it might as well be random.

In my case, a relatively small dose of an ordinary SSRI allowed me to gain enough control over my life that I could arrange to eliminate many of the triggers. I didn't need therapy to figure out that I needed an income to be able to buy my own food, for instance. Even today, being able to go to the grocery store, fill up my cart and know I can pay whatever the bill is gives me a huge thrill. Because I remember what it was like to have $1.47 for three days worth of food. My environmental triggers were not complicated; they were pretty low on Maslow's scale. And I could manage them without therapy just fine.

In someone else's case, where the environmental problems are a little higher up, sure, therapy would clearly have more of a role.

Back when I was fourteen and had my first major depressive episode with suicidal ideation a therapist I adored would probably have been able to help. By the time I was thirty-three and had pulled myself through one or two depressive episodes every year since then - some of them truly life-threatening - I had the perspective to know that if I could just survive it I would be ok. I didn't need therapy for that either. I just needed a job, and to know that it wouldn't be disrupted by another episode.

"And even if you have a problem like bipolar disorder or schizophrenia or OCD, things that are very biochemical in nature, learning to cope better with them is always a boon. They can help you take fewer medications and deal with how badly your remaining symptoms affect your day-to-day life."

Yup. And in my case, once I was on meds I could actually *do* almost everything I needed to keep myself stable. I never needed a high dose.

"And for all the wonders of meds, they all have side effects, some of them less pleasant than others."

A dry mouth can be handled with chewing gum. I'll take chewing gum over hunger any day. Really.

*** *** ***This is a completely different discussion than the one about whether some therapists might feel that therapy is a good thing in and of itself whether or not it's helping or even if it appears to be harmful.

You're talking about how therapy can be helpful. It can be, absolutely. And even though I rely primarily on my meds and my own desire to live, I do have a therapist as backup. She's helpful. She's not who I'm talking about. (Well, she might be for someone else - she thinks meds are a crutch and doesn't fully believe that I don't have getting off meds as one of my goals. So perhaps she's stringing someone else out on therapy and discouraging them from getting appropriate medical help and telling them that their depressive episode is a sign that they're dealing with important issues and doing good work. I don't know. But at this point I'm able to be directive and to cut off any conversations about how nice it would be to get off meds. If it ain't broke, don't fix it. )

I have so much to say, but I am nearly speechless. I have both love and hate feelings towards my therapist.

Sometimes I feel like I try too hard to win his approval. Sometimes I feel like he is "re-parenting" me. And sometimes I just feel like a number, a means in which he makes money.

I don't know if therapy is working. I feel just as depressed as I was a year ago. In fact, I feel as if my life is in more danger from the monster inside of me.

I have actually talked to my therapist about my "safety" plan, and that I didn't think he should be a part of it. Whenever I called him in despire, I felt he took five steps away from me...as his boundries became lead fortified. I felt strong feelings of rejection...which led me to feel even worse.

I wonder if I should be with a therapist that I cannot count on...when I am deeply hurting.

I guess this is all a borderline thing.

I guess therapy is working, because I kept myself alive. However, after every moment of suicidal idealization, I have discovered more lethal and less painful ways to.....well anyways.

I do isolate myself...and my screams are silent...as they only exist in slowly typed words.

I would never wish this hell upon anyone. And I do very much want to live without these thoughts of death, and without this enduring pain.

So I wonder....Is my therapist helping me?And how long can someone endure the hell of depression...before they extingish?

No progress for me. I mean, I guess that between last year and this year I didn't kill myself. Wow.

So I exist. Barely making it through the workweek. Sleeping all weekend. Hopeless about the future.

Still see therapist every week. Still see psychiatrist about once a month except July when he cancelled our apt. on the 5th due to vacation. In all fairness I was going to cancel it too.

I look at alternatives such as neurotherapy. There is no relief for the daily boredom and emptiness I feel. I feel no hope for the future. Everything I've ever wanted has been denied me.

Maybe I would be better off using the $190 per shrink visit as toilet paper. Therapist is free. I need to get him on track or something. In the meantime, I'm looking forward to going home and going to bed. Also, I've discovered YouTube where I can hear therapists whine and psychiatrists speak!